INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 10, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia DRC, Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to identify the specific information to be disclosed in 6 of 9 records reviewed.
Client records # 2, 3, 4, 6 & 8 contained consent to release information forms to family where the area for information to be released had "other" checked, but, lacked documentation as to what other information was to be released. Additionally, all other checkboxes for information were checked, even those that would not be appropriate for family members.
Client records #3, 4 & 6 contained consent to release information forms to the funding source where the area for information to be released had "other" checked, but, lacked documentation as to what other information was to be released.
Client record #2 consent form dated 10/3/16 - release to family.
Client record #3 consent form dated 8/2/16 - release to family, 8/2/16 release to funding source.
Client record #4 consent form dated 7/6/16 - release to family 7/67/16 release to funding source.
Client record #6 consent form dated 8/29/16 - release to family 8/29/16 release to funding source..
Client record #8 consent form dated 7/20/16 - release to family.
Client record # 9 contained a consent form dated 7/25/16 for an "Emergency Contact"; however, no name was provided.
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Plan of Correction
Plan of Correction:
All consent to release information forms will identify specific information to be disclosed.
The Intake Supervisor will review consent to release information forms to see that the checkboxes are appropriate.
There will an in-service staff training on completing consent to release information forms at an Outpatient Staff meeting on 1/24/17.
The consent to release information forms to family for clients #2, 3, and 4 were redone with the respective clients.
The consent to release information forms to family for clients #6 & 8 could not be corrected because these clients have been discharged from the program.
The consent to release information forms to family for clients #3 and 4 were redone with the respective clients present and the "other" was not checked.
The consent to release information form to family for client #6 could not be corrected because the client has been discharged from the program.
The consent shall expire 1 year from the consent date. The expiration date was corrected with client #2.
The consent to release information should be specific to person, facility or organization.
The consent to release information was corrected with Client #3 to be specific for person.
The consent to release information was corrected with Client #4 to be specific for person.
The consent to release information form for client #6 could not be corrected because the client has been discharged from the program.
The consent to release information form for client #8 could not be corrected because the client has been discharged from the program.
The consent to release information should be specific to person, facility or organization. Record #9 Emergency Contact name was provided on Intake Screening Form. The consent to release information form for client #9 could not be corrected because the client has been discharged from the program.
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to identify the purpose for the release of information to be disclosed in 5 of 9 records reviewed.
Client records # 2, 3, 4, 6 & 8 contained consent to release information forms to family where the purpose for the release of information was not documented. The consent to release information forms had multiple checkboxes to select from based upon the purpose for the release. Rather than selecting those that would be applicable for releases of information to family members, all checkboxes were selected, some of which would not pertain to the release of information to family.
Client record #2 consent form dated 10/3/16 - release to family.
Client record #3 consent form dated 8/2/16 - release to family.
Client record #4 consent form dated 7/6/16 - release to family.
Client record #6 consent form dated 8/29/16 - release to family.
Client record #8 consent form dated 7/20/16 - release to family.
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Plan of Correction
All consent to release information forms will identify specific information to be disclosed.
The Intake Supervisor will review consent to release information forms to see that the checkboxes are appropriate.
The purpose of the release of information will be indicated on the consent form. Only those checkboxes applicable to the release of information for family members will be checked.
Client record #2 was revised to reflect applicable checkboxes for family.
Client record #3 was revised to reflect applicable checkboxes for family.
Client record #4 was revised to reflect applicable checkboxes for family.
Client record #6 was revised to reflect applicable checkboxes for family.
Client record #8 was revised to reflect applicable checkboxes for family.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history, drug and alcohol history, and personal history in three of ten client records reviewed.
The findings include:
Cleint #1 was admnitted on September 7, 2016. There was no documentation of medical, drug and alcohol or personel histories in the client record as of the date of this inspeciton.
Cleint #8 was admnitted on July 20, 2016 and discharged on September 14, 2016. There was no documentation of medical, drug and alcohol or personel histories in the client record as of the date of this inspeciton.
Cleint #9 was admnitted on July 25, 2016 and discharged on October 4, 2016. There was no documentation of medical, drug and alcohol or personel histories in the client record as of the date of this inspeciton.
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Plan of Correction
The Addiction Severity Index (ASI) is completed during the intake process. The ASA is a standard interview that provides history in seven potential problem areas: Medical, Employment/Support Status, Alcohol, Drug, Legal, Family/Social, and Psychiatric.
The Intake Supervisor will review intake documentation daily to ensure that the ASI has been completed.
The Clinical Supervisor will review intake documentation to ensure that the ASI has been completed when doing monthly open chart audits.
There will an in-service staff review for the Intake-Assessment Department on completing the Addiction Severity Index at a staff meeting on 1/27/17.
Client #1 ASI was completed during Intake on 9/7/16 and filed in the chart.
Client #8 ASI was completed during Intake on 7/20/16 and filed in the chart.
Client #9 ASI was completed during Intake on 7/25/16 and filed in the chart.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a Biopsychosocial evaluation in five of ten records reviewed and a Biopsychosocial evaluation that was evaluative in one of ten records reviewed..
The findings include:
Client #1 was admitted on September 7, 2016. There was no documentation of a Biopsychosocial evaluation in the client record as of the date of this inspection.
Client #4 was admitted on July 6, 2016. There was no documentation of a Biopsychosocial evaluation in the client record as of the date of this inspection
Client #6 was admitted on August 29, 2016 and discharged on September 23, 2016. There was no documentation of a Biopsychosocial evaluation in the client record.
Client #7 was admitted on July 22, 2016 and discharged October 27, 2016. There was no documentation of a Biopsychosocial evaluation in the client record.
Client #8 was admitted on July 20, 2016 and discharged on September 14, 2016. There was no documentation of a Biopsychosocial evaluation in the client record as of the date of this inspection
Client #9 was admitted on July 25, 2016 and discharged on October 4, 2016. The Biopsychosocial evaluation in client record #9 was not evaluative. The summary mainly stated the client reports, as opposed to actually providing an evaluation and assessment.
The findings were discussed with facility staff.
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Plan of Correction
The client will meet with Primary Counselor for individual counseling sessions once weekly. The counselor will begin gathering data to complete the Psychosocial History. Upon completion of the Psychosocial History the counselor will write a psychosocial assessment and submit to Clinical Supervisor for review prior to the next individual session.
Psychosocial histories, completed on the computer, will be placed in the clinical chart at the conclusion of the session. There will be no sub-folders kept on clients.
Open chart audits will be done weekly by Clinical Supervisor to ensure the bio-psychosocial has been done.
The Program Director will monitor due dates for psychosocial weekly.
There will an in-service staff review on completing the
bio-psychosocial during the Outpatient Staff meeting on 1/31/17.
Client #1 Bio-psychosocial was completed on 9/28/16 by primary counselor and has been placed in the clinical chart
Client #4 Bio-psychosocial was completed on 8/16/16 by primary counselor and has been placed in the clinical chart
Client #6 Bio-psychosocial was not completed by primary counselor due to failure to return to treatment after two weeks of participation. The incomplete bio-psychosocial is in the clinical chart.
Client #7 Bio-psychosocial was completed on 5/21/16 by primary counselor and has been placed in the clinical chart.
Client #8 Bio-psychosocial was not completed by primary counselor due to inconsistent treatment attendance. The bio-psychosocial could not be completed because the client has been discharged from the program.
Client #9 Bio-psychosocial evaluation was reviewed with primary counselor by the Program Director. The evaluation and assessment were revised to be evaluative.
There will be an in-service staff training on clinical observations and assessment during the Outpatient Staff meeting on 1/31/17.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individualized treatment plan seven of ten records reviewed.
The findings include:
Client #1 was admitted on September 7, 2016. There was no documentation of an individualized treatment plan in the client record as of the date of this inspection.
Client #2 was admitted on October 3, 2016. There was no documentation of an individualized treatment plan in the client record as of the date of this inspection.
Client #3 was admitted on August 2, 2016. There was no documentation of an individualized treatment plan in the client record as of the date of this inspection.
Client #5 was admitted on October 5, 2016. There was no documentation of an individualized treatment plan in the client record as of the date of this inspection.
Client #7 was admitted on July 22, 2016 and discharged October 27, 2016. There was no documentation of an individualized treatment plan in the client record.
Client #8 was admitted on July 20, 2016 and discharged on September 14, 2016. There was no documentation of an individualized treatment plan in the client record.
Client #9 was admitted on July 25, 2016 and discharged on October 4, 2016. There was no documentation of an individualized treatment plan in the client record.
The findings were discussed with facility staff.
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Plan of Correction
An Individual treatment plan shall be developed with each client after the completion of the client's bio-psychosocial assessment and maintained in the client's record.
The Program Director/Clinical Supervisor will review and sign individual treatment plan.
The individual treatment plan will be kept in the client's clinical chart. There will be no sub-folders kept on clients.
There will an in-service staff review on completing the
Individualized Treatment Plan during the Outpatient Staff meeting on 1/31/17
Client #1 individual treatment plan cannot be completed because the client has been discharged.
Client #2 individual treatment plan was completed with the client on 11/2/16 and was located and placed in the chart.
Client #3 individual treatment plans were completed with the client on 9/1/16, 9/30/16, & 10/7/16 and were removed from a sub-folder and placed in the chart.
Client #5 individual treatment plan was completed with the client on 10/17/16 and placed in the chart after it was signed by the doctor.
Client #7 individual treatment plans were completed with the client on 6/5/16, 7/5/16, 7/22/16 & 9/22/16 and were removed from a sub-folder and placed in the chart.
Client #8 individual treatment plan was completed with the client on 8/15/16. It was located and placed in the chart.
Client #9 individual treatment plan cannot be completed because the client has been discharged.
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709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of client records, the facility failed to document a complete client record in three of ten records reviewed.
The findings include:
Client #6 was admitted on August 29, 2016 and discharged on September 23, 2016. There was no documentation of a discharge summary in the client record.
Client #7 was admitted on July 22, 2016 and discharged October 27, 2016. There was no documentation of an aftercare plan or case consultations in the client record.
Client #9 was admitted on July 25, 2016 and discharged on October 4, 2016. There was no documentation of any case consultations in the client record.
The findings were discussed with facility staff.
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Plan of Correction
A discharge summary shall be completed on all clients who have been officially admitted to the program, regardless of the length of the treatment episode or the status of the discharge.
The Primary Counselor shall be responsible for completing the discharge summary within one week of discharge. The Program Director/Clinical Supervisor shall review and sign the discharge summary. Program Director/Clinical Supervisor will review due date for discharge summaries needed during the Outpatient weekly staff meeting.
There will be an in-service staff review on completing the
Discharge Summary during the Outpatient Staff meeting on 1/24/17
Aftercare planning is initiated during the first week of treatment. Each client being considered for treatment completion must complete an individualized aftercare plan.
A Case consultation is done within 60 days and then every 60 days afterwards. During clinical staff meeting the primary counselor shall present a verbal case report for case consultation and treatment progress shall be documented on case consultation form.
The Program Director/Clinical Supervisor will do monthly open chart audits to assist primary counselors with timely case consultation presentations. The case consultations will be presented, documented and promptly placed in the client's chart. There will be no sub-folders kept on clients.
There will an in-service staff review on completing the
Case Consultations during the Outpatient Staff meeting on 1/24/17
Client #6 discharge summary has been completed by primary counselor, signed by Clinical Supervisor and placed in the chart.
Client #7 has an Aftercare Plan signed by client and primary counselor dated 10/28/16.
Client #7 has Case Consultations dated 7/22/16 and 9/5/16 in the chart.
Client #9 has a Case Consultation in the chart dated 9/27/16.
There will an in-service staff review on completing the
Individualized Treatment Plan during the Outpatient Staff meeting on 1/31/17
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